2004 HOUSTON AREA NATIONAL SUMMER TRANSPORTATION INSTITUTE by HC12073019225

VIEWS: 0 PAGES: 4

									         2009 HOUSTON NATIONAL SUMMER TRANSPORTATION INSTITUTE
                        APPLICATION FORM FOR SECONDARY SCHOOL STUDENT

STUDENT INFORMATION
First Name___________________ Middle _____ Last Name ___________________________ Date _____________________

Gender ___________ Age ________ Ethnicity (Optional) _______________________

Home Address _____________________________________________________________________________________________

City ____________________ County ________________ State ___________________ Zip ______________________________

Telephone: Home    (____) _________________Work (_____) _________________ Email_________________


PARENT INFORMATION
Parents/Guardian _________________________________________________________________________________________

Address (if different) ______________________________________________________________________________________

Telephone: Home    (____)________________Work (_____)_________________ Email_________________

SCHOOL INFORMATION
School Attending (Fall 2009-2010) ________________________Grade ____ GPA ____ Standardized Test Scores ________

School Mailing Address ___________________________________________________________________________________

City ____________________ County ________________ State ___________________ Zip ______________________________

Guidance Counselor _____________________________________________________________________________________

Telephone__________________________ Fax________________________ E-Mail ____________________________________


Career Interest (Circle One)

        Accounting        Architecture      Business       Criminal Justice         Computer Science      Construction
        Engineering       Environmental     Law    Marketing       Scientific Research   Technology      Transportation


Indicate T-Shirt Size (Circle One)                     S       M        L        XL      XXL     Other


Required Essay:           Describe your career objective(s), your interest in transportation, and how the Summer Transportation
                          Institute can assist you in reaching your goals. Your essay must be typed, and can not be more than one (1)
                          page.
Additional Information:

Please enclose one letter of recommendation and your academic transcript. Applications will not be processed with incomplete
information. All materials must be provided to the Project Coordinator at the below address no later than Monday, May 25,
2009.

Inquiries:        Tasjah D. Hall, Project Coordinator
                  2009 Houston Area National Summer Transportation Institute
                  CENTER FOR TRANSPORTATION TRAINING AND RESEARCH
                  Texas Southern University
                  3100 Cleburne
                  Houston, TX 77004
                  Phone: (713) 313-1959 Fax: (713) 313-1923 E-Mail:Halltd@tsu.edu
                                                            HEALTH HISTORY


Please fill out this form as it is for your child’s safety and welfare while on campus and during all activities.
The signature of a physician is NOT required. Please print clearly.

Name: _________________________________________________________________________________________________

Street Address: __________________________________________________________________________________________

City ______________________          State ________________________ Zip _________________________

Age ________________ Gender _______________________

Past and Present History of Illness or Injury:

Does your child have a history of any of the following:

1.   Disability or Health Problem:

2.   Heart Problem (Mitral Valve Prolapse, Murmur):

3.   Lung Problem (Tuberculosis, Asthma):

4.   Neurological (Seizures, Migraine):

5.   Mental (Nervousness):

6.   List any past injuries or hospitalizations:

7.   Has he/she ever passed out?

8.   List any lengthy illness:

9.   List any vision problems:

10. Sinusitis:

11. Hearing Loss:

12. Anemia / Sickle Cell Disease or Trait:

13. Rheumatic Fever:

14. List any injury or broken bones:             Neck                Elbow               Back
                                                 Collar Bone         Wrist               Pelvis
                                                 Ankle               Shoulder            Hand
                                                 Arm                 Ribs                Leg

15. List any physical challenges:

16. Is he/she on any medications?

17. List any allergies to food, medications, plants, etc.

18. Please list any injuries or conditions not included above.
I certify that the above information is true and that the individual named on this form is in good health and able to take part in all
2009Houston Summer Transportation Institute activities at Texas Southern University with the exceptions that I have written in this
form.

I also understand that no physician is available on the campus of Texas Southern University during the summer; however, professional
nurses will be available. I give permission for limited treatment for minor illnesses and/or injuries. Emergency illness will be referred
to the nearest medical facility for care at the expense of the parent or qualify under insurance provided by the Institute.



Signature (Parent/Guardian)                                              Date


Phone Number to Contact in the Event of an Emergency


Primary Care Physician                                                   Physician’s Phone Number
                                                REGULATIONS

We are excited to have you join use for the 2009 Houston Area National Summer Transportation Institute. We
are responsible for your safety and well being at all times. Guidelines, rules, and regulations are important and
necessary to meet the objectives of the program. The following are regulations for Institute participants:

1. Institute staff expects participants to display courteous and professional behavior toward their peers, faculty,
   staff, and professionals at all times.

2. Attendance at all program activities is mandatory. Only excused absences from the Institute Director will
   be accepted. Students must report illness, injury, etc., to the Institute Director and Project Coordinator to be
   excused from activities. Violations may lead to dismissal from the program.

3. Students are not permitted to leave campus unescorted. Any student found or reported off campus is subject
   to immediate dismissal.

I have read and understand the above regulations.



Print Name (Student) __________________________________________________________________


Signature (Student) _____________________________ Date _________________________


Print Name (Parent/Guardian) __________________________________________________________


Signature (Parent/Guardian) ________________________          Date _______________________________

								
To top